Missed Antibiotic Doses Result in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors by not administering the full prescribed course of antibiotics to two residents. For one resident with chronic respiratory conditions, including COPD and chronic respiratory failure, the medical record showed that a 7-day course of Doxycycline was ordered and 14 pills were supplied by the pharmacy. However, after several days of administration, it was observed that there were eight pills remaining on the medication card when there should have only been five, indicating that three doses had been missed. The Acting Director of Nursing confirmed that only one dose was pulled from emergency stock and that there was no other source for the medication, verifying the missed doses. Similarly, another resident with diagnoses including schizoaffective disorder and chronic kidney disease was prescribed the same antibiotic regimen. Observations revealed that five pills remained on the medication card when there should have been only three, indicating that two doses were missed. The Acting Director of Nursing again confirmed the discrepancy and the importance of administering the full course of antibiotics. Facility policy required medications to be administered according to orders, but this was not followed, resulting in significant medication errors for both residents.